The baby who is below birthweight at 8 wks is not a slow gainer. He is not 
gainingat all, and has lost weight. I agree totally with Sharon's assessment 
and feel this is quite the emergency situation.
My guess, based on the history of this and earlier babies, is that mother 
could very well have primary lactation insufficiency or insufficient milk 
supply syndrome, whatever you want to call it. As Sharon said, there could 
be some anatomical finding in baby or a low tone issue that is genetic but I 
think more likely it would be a maternal finding. Just my hunch. What is 
usually very telling is breast growth and changes in pregnancy, but 
especially on day 3-5 postpartum. If a mom tells me "I'm not sure my milk is 
in" or "I think I have milk" or something vague and unsure, I worry. Usually 
when I ask "Did your milk come in" they answer "OH YEAH" or "I feel like I 
have implants" or something like that. I find the milk surge is usually a 
very obvious phenomenon. Of course the milk could have come in with 
abundance, but if the baby was transferring poorly it usually down regulates 
very quickly.
I also don't trust wet diapers alot. I've seen quite a few poor gaining or 
losing newborns with a good wet diaper count per the mom. I find the stools 
are much more telling and I like to see an abundance. Since I believe babies 
can have a normal decrease in stool frequency after about 6 wks, I would not 
find that the stool count would necessarily be very helpful at 8 wks out.
An average sized newborn needs about 20-25 oz of milk per day, so if mom is 
supplementing a few ounces or, say, 1 - 2 oz after 8 feeds, that is only 8 - 
16 oz per day. If she is putting out only a few cc's, which can certainly be 
the case, you can easily see how this baby would be starving.  I have seen 
this before, but never in an older baby. I am following newborns and 
intervene very early. I have also had moms who were very very reluctant to 
supplement until they saw a milk transfer on a digital scale and had it all 
laid out for them in terms of what a baby needs etc. Of course it is 
difficult for the mother and disappointing if primary insufficiency and she 
needs emotional support. Of course, I will help the mother optimize the milk 
production and milk transfer with the usual array of strategies. I offer 
options and the mother chooses the method of supplementation. 
Overwhelmingly, mothers choose bottles.
If you can, Fio, let us know what the resolution of the situation is.

Laurie Wheeler, IBCLC, MN, RN
New Orleans Louisiana, s.e. USA

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